The role of the Division of Gynecologic Oncology at BC Cancer is to serve as a consultative and treatment service to patients with gynecological cancer in the province. Physicians are encouraged to consult with the group if they have concerns regarding any aspect of the diagnosis and management of patients with gynecological cancer. BC Cancer has a toll free number for this purpose: 1-800-663-3333, locals 2353, 2365 or 2367. Members of the divisional medical staff may be reached at these numbers.

It is the policy of the Gynecology Tumour Group to try and have all new patients discussed at a Gynecologic Oncology Disposition Clinic. The Friday Disposition Clinic is video linked with the Vancouver Centre, Fraser Valley Centre, Vancouver Island Centre and the Centre for the Southern Interior. This facilitates patient consultation and discussion of difficult clinical problems by this multidisciplinary group.

At this clinic, the patient's history, physical findings, laboratory reports and pathology slides are reviewed and discussed by members of the group. A treatment decision is arrived at and recommendations made to the patient and the referring physician. Those patients requiring surgery other than radical surgery are referred back to their attending physician unless it is the physician's desire that the surgery be performed by BC Cancer consulting staff. A Gynecologic Oncology opinion is available and is recommended even if it is anticipated that treatment is to be given entirely in the patient's own community in order to ensure uniform standards and quality throughout the province. This would also help to avoid undesirable delays in patient treatment because of failure to appreciate the "high risk" nature of lesions based on their histology.

A social worker who is attached to the Tumour Group is available to assist patients and their families with arrangements, etc.

The Department does conduct Tumour Conferences for the discussion of unusual or difficult management problems. This Conference is available for a more formal review of a patient management problem at the request of any physician.

Delay in the initiation of treatment and considerable patient anxiety can also occur because pertinent pathology and operative reports are not available. It would greatly facilitate matters if the referring physicians would send such reports and slides prior to the time the new patient appointment is requested. Frequently, patients discover at their new patient appointment that the time required for treatment is much longer than they realized. This has implications for their accommodation arrangements and, of course, for the general stress associated with the diagnosis of cancer. The average treatment times for standard course of radiotherapy employed for the common gynecological tumours is detailed in the sections listed on the menu bar.

As malignant pelvic tumors arising from the ovary or fallopian tube commonly involve the small or large bowel, preparation of the bowel prior to an operative intervention is essential.

Patients should be held to reduce their oral intake to clear fluids only, 36 hours prior to the intervention. The bowel preparation should be performed on the afternoon of the day prior to the proposed surgery. 15 mg of Maxeran should be given orally, ½ hour before commencing with the bowel preparation.

For patients with a high likelihood of advanced or metastatic ovarian cancer presenting with a fixed pelvic mass and/or ascites and/or evidence of upper abdominal disease, should undergo gastrointestinal lavage with an electrolyte solution prepared specifically for this purpose. Typically this consists of a powdered electrolyte preparation which is supplied with a 4.8 liter jug. Four liters of water are added to the powder to make up the total volume of 4.8 liters.

Patients that have a low likelihood of advanced or metastatic cancer or that are unable to tolerate the above regimen should substitute the electrolyte solution for two bottles of 295 ml magnesium citrate solution USP. In addition to that the patient should receive two tablets of phenolphthalein, 130 mg each, as well as a suppository of 10 mg bisacodyl USP.

At the time of start of the operative procedure the patient should receive 80 mg of gentamycin intravenously and 500 mg of Flagyl intravenously.

Please note that the use of enemas is no substitute for the above bowel preparation regimens.

Few topics evoke more controversy and dogmatic opinion than the issue of estrogen replacement in women with gynecologic malignancies.

The relationship between estrogen therapy and endometrial carcinoma is well known. The effect of estrogen replacement on other gynecologic malignancy is less clear. Estrogen receptors have been identified in all mullerian tissues. There are reports of partial responses of epithelial ovarian cancer to anti-estrogen medications suggesting that there may be a role for estrogen in the tumour growth.

The beneficial effects of estrogen replacement include vasomotor stability, prevention of vulvar and vaginal atrophy, and (epidemiologically the most important) a positive effect on the prevention of osteoporosis and a protective effect from vascular disease.

Progestogen therapy is much more controversial. Progestogens are known to protect the `at risk' endometrium from developing cancer. The effect of exogenous progestogen on breast cancer incidence has recently come into question. Certainly even a small increase in relative risk would be a major concern in a disease as common as breast cancer.

Still another reservation held about synthetic progestogens is their effect on serum lipids. These compounds tend to reverse the potential protective effects of estrogen by lowering the HDL and raising the LDL.

A policy of hormone replacement to reflect the above concerns is presented. Clearly this area is dynamic and our understanding of these hormones, their receptors and their relationship to both the development and the treatment of gynecologic tumours, is continually developing. This document attempts to use the current state of our knowledge to provide a rational policy for hormone replacement in gynecologic oncology patients.

For patients with potential estrogen sensitive tumours, hormone replacement should be directed towards symptom control and avoided for the general prophylaxis against ASHD, Osteoporosis etc.

When hormones are considered necessary, no waiting period is necessary.

Note: this represents the consensus opinion of the Gynecologic Oncology Group at BC Cancer. These recommendations have also been reviewed and accepted by the Breast Tumour Group.

This section is intended as a guide to the average length of time required for standard radiotherapy used for common gynecological malignancies. It may be helpful for counseling your patient, but final treatment recommendations will need to be made on an individual basis.

1. External Beam Radiotherapy

Treatment to the pelvis usually requires five weeks of daily visits. Treatments only take a few minutes per day, and are given Monday through Friday. Prior to starting treatment, patients require an additional appointment for simulation and planning, where appropriate fields are outlined and radiation doses are calculated.

Treatment for ovarian cancer is usually given to both the upper abdomen and the pelvis. This is a longer program, lasting for 6.5 weeks of daily visits.

2. Brachytherapy

a) Vaginal Vault Treatment after Hysterectomy

This can either be given as an additional "boost" treatment following external beam therapy, or alone as the only form of radiation therapy.

Outpatient TreatmentTreatment can be given on an outpatient basis using a "high dose rate" radioactive iridium source. The procedure involves inserting a plastic applicator (referred to as the vaginal obturator or cylinder) into the vagina. These come in different sizes. The iridium source is placed inside the applicator. The treatment only takes a few minutes, and the patient is able to go home right away afterwards.

Inpatient TreatmentTreatment can be given on an inpatient basis using "low dose rate" cesium pellets. A plastic applicator is inserted into the vagina, and attached to a belt to hold it into position. Patients require a urinary catheter and enema before this procedure, as it may last from 3 to 18 hours during which time they must remain recumbent in bed. For the 18 hour treatment time, this may result in an overnight hospital stay.

b) Intrauterine Treatment for Cervix/Endometrial Cancers

Usually patients will also be receiving 5 weeks of external beam therapy, as well as these additional treatments to give a high dose of radiation to the areas of gross disease.

Outpatient Treatment

Treatment can be given on an outpatient basis using the "high dose rate" radioactive source. This requires 3-5 separate treatments. Each treatment requires dilation of the cervix, with placement of a tube through the cervix into the uterine cavity. This requires sterile technique, and either sedation or anaesthetic. The patient will not need to stay overnight in hospital. This outpatient procedure is not yet available at all centers.

Inpatient Treatment (Selectron)Patients are admitted to hospital, and intrauterine and intravaginal tubes are placed under a general or spinal anaesthetic. The procedure takes about 90 minutes to perform. After recovery from the anaesthetic, patients are returned to the hospital ward where radioactive cesium pellets are loaded into the tubes. The patients usually require about 24 hours of bedrest with the tubes in place, so they need a urinary catheter and enema. They are usually able to go home a few hours after the tubes are removed. This procedure is usually done twice, separated by one week.

c) Primary Vaginal Cancer Treatment

Inpatient Treatment (Interstitial Implant)

On rare occasions, patients may require a temporary interstitial implant for tumors originating in the vagina. This procedure is done under general or spinal anaesthetic, and may require admission to hospital for up to 5 days of bedrest for treatments. Plastic tubing or stainless steel needles are placed directly into the tissue to allow sources to be placed directly into the tissues. At the end of the treatments, the sources and tubing are removed. This is generally more uncomfortable for the patients, requiring considerable supportive care in hospital and analgesics.

The patient should be referred as soon as a diagnosis is made and should ideally be scheduled to attend the new patient clinic within 7-10 days of their surgery. Urgent appointments are required for patients with a germ cell tumor of the ovary (embryonal carcinoma, yolk sac carcinoma, endodermal sinus tumor, teratoma, choriocarcinoma), choriocarcinoma or pregnancy, gestational neoplasia or molar pregnancy.

Delay in the initiation of treatment and considerable patient anxiety can occur because pertinent pathology and operative reports are not available at the time of the new patient appointment. It would greatly facilitate matters if the referring physicians would send such reports (follow this link) as soon as possible when making a referral.

Patient and Family Counselling Services offers a number of support programs and services to patients and their families. For more information please contact 604.877.6000, local 2194 or toll free (in B.C.) at 1.800.663.3333 local 2194.

The Library at 604.675.8001 or toll free (in B.C.): 1.888.675.8001 ext. 8001 is a valuable resource.

Recommended Links to websites on cancer and health are compiled and evaluated by BC Cancer Librarians and BC Cancer experts.